Psychosis

Question 1

What is madness and what does psychosis come under?

Answer 1

People who hear voices/ disorganised behaviour/ thought disorder considered differently to other mental illnesses and are seen as less relatable and put in a separate box.

Psychosis comes under madness.

Question 2

Explain delirium.

Answer 2

Brain failure → Reasons external or internal to the brain, brain is no longer, at this point in time, able to do all of its functions.

Fluctuates and goes away and people can appear very strange at one point and quite well later.

Question 3

Encephalopathy, Acquired Brain Injury, Stroke

Answer 3

Symptoms present in slightly different way, depending on what the particular injuries are.

Question 4

Dementia - Long term

Answer 4

Brain/mind is losing it’s functionality.

Alzheimer’s, Vascular D, Parkinson’s.

Person losing their grasp on reality.

Question 5

Explain what a personality disorder is.

Answer 5

Seen in people who’ve experienced huge amounts of trauma or abuse and have developed things like personality disorders.

Might have symptoms called Parapsychotic symptoms → Symptoms where it’s as if they’re hearing the voice of someone who abused them or caused them a huge amount of trauma.

PTSD.

Usually related to events that have happened to the person, but they can seem quite psychotic and mad at the time.

Question 6

Explain what schizophrenia is.

Answer 6

More true psychosis.

Disease of the mind/brain.

Brain is really misfunctioning and why we get classical psychotic symptoms.

Not all people with psychotic symptoms are going to be having schizophrenia.

Question 7

What is puerperal psychosis?

Answer 7

Psychosis related to giving birth

Question 8

What drugs can cause delirium and psychosis?

Answer 8

Cocaine, LSD, Cannabis, alcohol

L-Dopa, steroids, anticholinergics

Question 9

What metabolic disorders can cause delirium and psychosis?

Answer 9

Ca2+, Mg2+, Cu2+, Vit B12

Question 10

What endocrine conditions can cause delirium and psychosis?

Answer 10

Thyroid, Cushing’s, Addison’s

Question 11

What infections can cause delirium and psychosis?

Answer 11

Encephalis, syphilis, any

Question 12

What is psychosis?

Answer 12

Made up of combinations of:

Hallucinations (perceptual abnormalities of hearing, sight, smell, tactile) ,

Delusions (fixed and false beliefs where someone might become very paranoid or persecuted; equally someone might become grandiose or withdrawn or have delusions of guilt that they’re responsible for something that’s nothing) and/or

Thought Disorder(brain’s thought patterns and processing becomes so disordered that their speech and thought process is also quite disordered and it’s really hard to follow what’s going on).

REALITY FAILURE- The brain isn’t able to process what’s going on in reality, and so to you and I, what they then do looks completely bonkers or completely mad.

They tell us this story and you think this is just not true, but for that person, that is really what’s happening and that’s their experience. In reality, we’re just seeing one side of the picture and actually they experience a very different thing inside their own minds.

Question 13

List a group of pathologies which disrupt the perceiving and interpreting reality.

Answer 13

Delusions, hallucinations, clear consciousness and intellectual capacity usually preserved, thought disorganisation, various causes, abnormal attention/salience.

Question 14

Explain reality failure.

Answer 14

Psychosis usually defined as hallucination and delusions (brain trying to process accurately all this information that’s coming in from the sense organs and trying to piece it all together).

However, bearing in mind that most of the purpose of the CNS is to accurately perceive and interpret information about the outside world, these 2 seemingly discrete symptoms actually describe quite an overarching and non-specific deficit.

Equivalent to medical diagnosis of Off Legs. So psychosis presents a large group of different disease processes which are grouped together purely because they all share an end result which looks broadly similar.

Question 15

What is a persons consciousness?

Answer 15

Conscious probably modular, not unitary. → Parallel processing -battery of unconscious processes.

Content of conscious awareness is selected by attention → Both active/voluntary, and passive (salience and automatic screening of irrelevant stimuli)

May screen out things that are relevant → e.g. Autism - People find it really hard to process out irrelevant things and they can get hypersensitivity to things like touch.

Very individual sense of whats going on in the world.

Sensory input is modified pre-consciously to fit our expectations.

Question 16

Explain what auditory verbal hallucinations are.

Answer 16

Thoughts/internal monologue experienced as external/other.

For most people, they would have been thoughts as an internal monologue that we have, but for people who maybe have got hallucinations, they are experienced them as external or as other. So not their own, they are somehow foreign to them.

Experienced by ~5% of healthy population.

Question 17

What is a delusion?

Answer 17

Fixed, false, unshakable belief, out of context with cultural background (a belief in God is normal within a lot of cultural contexts - That’s accepted)

No one group of people, no one person has a totally full on view of what the truth of the whole world is. So delusions always have to be interpreted within the social and cultural context.

Question 18

What drives the formation of the delusional belief?

Answer 18

Intense feeling of being controlled/persecuted/culpable etc.

In persecuted populations, we do see slightly higher rates of psychosis symptoms.

Question 19

Why are delusions often persecutory?

Answer 19

The reason we also see lots of persecutory delusions in psychiatry is that that’s the default. When the world becomes uncertain and things become very unsure, the default position is something must be going on. Something’s happening to me, something has been done to me, perhaps because it’s your brain again, trying to save yourself, trying protect yourself from all those things that are happening out there and it’s part of the function of the brain. So it is adapting and trying to make sense of things and try and preserve your life, but it’s happening in a context that hasn’t maybe got the full picture.

Question 20

Explain what is meant by ‘positive’ symptoms of schizophrenia.

Answer 20

They’re actually added on to the normal human experience.

Question 21

What are the ‘positive’ symptoms of schizophrenia?

Answer 21

Hallucinations

Delusions

Persecutory/ Grandiose:
Delusional perceptions
Delusions of control
Thought delusions or interference.

Remember these experiences are very real for the patient → Leads to quite a lot of stigma.

Question 22

Explain what is meant by ‘negative’ symptoms of schizophrenia.

Answer 22

Missing from the normal human experience

Question 23

What are the ‘negative’ symptoms of schizophrenia?

Answer 23

Apathy
Blunted mood
Social withdrawal
Anhedonia - loss of enjoyment

Question 24

What are the disorganised symptoms of schizophrenia?

Answer 24

Thought disorder

Disorganised speech/behaviour

Inappropriate affect

Quite hard to sort of make sense for them, and they might seem quite perplexed, and they might have quite inappropriate affect. And by that, you might have a patient who’s just describing something that’s really distressing, but they’re just merrily laughing and you’re thinking, this is very weird.

Question 25

What may disturbance in fundamental components of experience/ self-awareness may include?

Answer 25

Perplexity:
Disruption of language/meaning.
Aberrantly salient experiences.
Overwhelmed by formless sense of Something Fishy Going On.

Disruption of the sense of self:
Your thoughts/experiences lose their ‘mine-ness’
Your internal world (mind/body) spills into external world.
The Other intrudes into your internal world.

Question 26

Outline the genetic component of schizophrenia.

Answer 26

Prevalence ~1% Heritability ~80%

Heritability from a single parent - 10% both parents ~50%, ~40% in monozygotic twins.

> 200 genes Multifactorial (epi)genetic cause most common, very few single gene causes.

A lot of the genes seem to be related to how dopamine 2 (D2) receptors are functioning.

Question 27

Explain the abnormal organisation of Default Mode Network in schizophrenic patients.

Answer 27

Stimulus-independent thought and self-reflection.

Abnormal default mode isn’t quite working correctly.

Question 28

Role of Dopamine.

Answer 28

Anticipated reward → directed attention.

Reward prediction error signalling.

Salience (sense of importance attached to perceptions)

Question 29

Working memory

Answer 29

Preconscious working memory stores large amount of data.
Allows you to contextualise the present moment.

Deficits in working memory → Thought and perception loses context, flow, order?

Question 30

List and explain the causes of psychosis.

Answer 30

Genetic component - Genes predisposing to SCZ must also confer significant advantage

Developmental adversity/abuse - Biased cognitive schemas (Being abused, being from war torn countries, having untrustworthy governments with their being lots of corruption around them). Sensitised striatal dopaminergic system. High expressed emotion, “double-bind” family dynamic.

Neurodevelopmental - Prematurity, hypoxia, winter/spring births, infections in the early part of childhood or in utero can also cause problems that can nudge towards developing schizophrenia.

Life stressors: Stress -vulnerability model

Relationship with recreational drugs - 25% of psychosis. Strong correlation with earlier age of cannabis use and strength of cannabis with onset of psychotic illness.

Question 31

List and explain some treatments for psychosis.

Answer 31

Antipsychotics - Antidopaminergic (also serotonergic, anticholinergic, antihistaminergic). “Typical” and “atypical”

Psychological therapies -
CBT for Psychosis
Avatar therapy (just real enough to be immersive) - patient gets to create a character on a computer and their therapist uses that character on the computer to talk to the patient and so to essentially challenge some of these beliefs and to give the patient more control over their own voices and more agency. So that they can rationalise and argue with themselves to try and abate some of the more difficult symptoms they have. Sense of agency over voices

Social support - Supportive environments, structures and routines.
Housing, benefits
Support with budgeting/employment.

Question 32

Explain the dopamine theory for psychosis.

Answer 32

Dopamine blockade

Neuroanatomy of dopamine pathways; cerebrum (cortical and limbic), striatum, pituitary.

Question 33

What are the side effects of medication for psychosis?

Answer 33

Neurological (EPSE, tardive dyskinesia, parkinsonism, dystonia, sedation)
Prolactin (amenorrhoea, erectile dysfunction, gynaecomastia)
GI (increased appetite, constipation)
Muscarinic (hypersalivation)
Haematological (neutropenia, agranulocytosis - especially clozapine)
Cardiac (arrhythmias, tachycardia, prolonged QTc)
Sedation

Question 34

Summarise psychosis.

Answer 34

Reality is not something we can claim unproblematic access to, it must accomodate the patient’s central reality → It’s real for them.

Psychosis is a complex syndrome, not a unitary disease process.

Psychosis represents a large group of different disease processes.

Don’t underestimate the social determinants of SCZ.

Try and understand the person, and why they have become psychotic.